Provider Demographics
NPI:1316360886
Name:HALVORSEN, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HALVORSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 OLD YORK RD
Mailing Address - Street 2:
Mailing Address - City:BORDENTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08505-4617
Mailing Address - Country:US
Mailing Address - Phone:609-203-2581
Mailing Address - Fax:
Practice Address - Street 1:2219 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:BORDENTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08505-4617
Practice Address - Country:US
Practice Address - Phone:609-203-2581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00600000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist